Healthcare Provider Details

I. General information

NPI: 1033932025
Provider Name (Legal Business Name): SHAVAR ROSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31946 MISSION TRL STE B
LAKE ELSINORE CA
92530-4539
US

IV. Provider business mailing address

40321 SALEM WAY
TEMECULA CA
92591-7530
US

V. Phone/Fax

Practice location:
  • Phone: 951-471-4300
  • Fax:
Mailing address:
  • Phone: 818-632-0885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: